Ainsley V. MacLean
BI 278
Dr. Boland
Dissociative Identity Disorder
J.D. is a friendly 27 year old woman with a history of dissociative identity disorder (DID).
She is moderately overweight with a pale complexion and is dressed neatly and casually in black
with dyed black hair. She slouches slightly, and her eyes remain focused on a defect in the rug at the
center of the room throughout the interview, except when a student asks a question when she makes
eye contact with them. She repeatedly wrings her hands in her lap and then runs them through her
hair. She speaks spontaneously and at a normal volume, but her speech is hurried and lacking
intonation. Intermittently she stumbles on her words. She is friendly and cooperative.
She reports feeling chronically anxious, and she is afraid that people are looking at her. This
prevents her from leaving the house, and makes her feel depressed. Her affect is blunted. When
speaking about her hopes for the future she uses words that convey excitement, but her affect
reflects none of these. Her thoughts are coherent except when speaking briefly about her past
experiences of abuse and other personality states, at which point they seem to become racing,
disjointed and chronologically disordered. She is never tangential, and always answers questions
directly. She has no thoughtblocking, loose associations, or perseveration. She denies hallucinations
and does not seem delusional. She speaks with remarkable insight about her disorder.
At age 4 she was placed in her first foster home in Alabama. Her memories of other
personality states begin when she was 10, when she recalls being abused by her foster mother. She
does not mention sexual abuse, but does mention verbal abuse and beratement for being overweight
and an embarrassment to the family. Following the abuse, she recalls escaping to her room for long
periods of time with her friend “Tracy”. She says that she has had Tracy, whom she refers to as her
“imaginary friend” as long as she can remember, and can recall that there were “others as well”,
nearly twenty. Her foster parents gave her up, and she was then transferred to another foster home
where after two years these foster parents also left her. This was when she first began “cutting” her
wrists. This made her feel better for a few minutes, like she was “crying blood”, but then she felt
badly again afterwards. The cutting ended only a few years ago.
She reported an incident at age 16, in which she was working at Walmart Headquarters.
There was a severe thunderstorm outside and she got very scared and was told that she hid under
her desk for 20 minutes or so. She recalls none of this, and lost the job because of this incident. A
few months later, she was raped. She decided to leave Alabama and move to RI, where her
biological mother was from. For several years following this she recounts that “they” took over, and
there “wasn’t any room” for her any more. She remembers coming home one day and her bed was
decorated like a little boy’s on one half and a woman’s on the other, and this frightened her
tremendously because she had no recollection of purchasing any of the items. Another frightening
incident was when she found herself in the “middle of nowhere” in the Midwest, and had no
recollection of driving there. At this point she decided to see a psychiatrist whom she recalls
laughed at her when she told him about her experiences. She then tried another psychiatrist whom
she liked because she “talked to all of us” and it made “the others feel included”. This psychiatrist
helped her to realize that “we all have to work like a team” and that she had to stop trying to make
the others disappear, but rather to make them all fit into her. For the past few years she has been
working towards this, and she seems to be moving slowly down a road towards better mental health.
The ways in which she integrates are varied. She gave the example of one of the personality traits
knowing German, and so she learned German, and that personality disappeared.
Today she says that she rarely switches, and only one or two of the personalities remain, and
these very seldom take over. She is currently on a selective serotonin reuptake inhibitor (SSRI), and
has participated in a partial hospitalization program at RIH which she felt helped her. She no longer
cuts her wrists, although she has considerable anxiety of going outside on the bus as she is under the
impression that everyone is laughing at her. For this reason, she spends most of her day in front of
the computer. She lives with two roommates; one is a woman whom she calls her fiancee. She
speaks periodically with her biological mother. She continues to learn German and computer
coding, and hopes to one day go to Germany and work there.
DID, formerly Multiple Personality Disorder, is defined by DSM-IV as fulfilling the
following criteria: 1) the presence of two or more distinct identities or personality states (each with
its own enduring pattern of perceiving, relating to, and thinking about the environment and self), 2)
At least two of the identities or personality states recurrently take control of the person’s behavior,
3) inability to recall important personal information that is too extensive to be explained by ordinary
forgetfulness, 4) the disturbance is not due to the direct psychological effects of a substance or a
general medical condition (in children symptoms are not attributable to imaginary playmates or
fantasy play).
Its prevalence has increased significantly in North America in the past two decades, and is
currently estimated to be about 1% of psychiatric inpatients. The causes of this increase in
prevalence are controversial, with many such as Dr. Paul McHugh writing that it is due to hypnotic
suggestion and professional fascination with the sensationalism of the multiple personalities. He
writes, “Ignore the alters. Stop talking to them, taking notes on them, and discussing them in staff
conferences. Pay attention to real present problems and conflicts rather than fantasy…then
psychotherapy can begin.” Others argue that it has been enhanced by an increase in awareness
amongst physicians about the disease, as well as a more extensive awareness of the prevalence of
childhood abuse.
There is strong evidence to support the evolution of DID, as well as other dissociative
disorders such as borderline personality disorder and post traumatic stress disorder (PTSD), as a
response to developmental, physical, and psychological trauma. Women with early-life sexual
trauma, particularly incest, are likely to have PTSD, or more severe identity disorders such as
dissociative. Many patients with DID also fit the criteria for PTSD. Additionally there is significant
co-morbidity with seizures and psychosomatic syndromes, as well as a tendency to hurt oneself.
Interestingly, because the patient’s description of other identities can appear as a form of
hallucination to an outsider, DID is sometimes confused with schizophrenia. When J.D. first started
talking about Tracy, I initially assumed that she was schizophrenic, because I suspected that Tracy
was a hallucination. The two can be differentiated through psychological testing because patients
with DID are much more easily hypnotizable than normals and schizophrenics.
Treatment for DID includes psychotherapy, hypnosis, and memory retrieval, with the longterm goal being integration and unifying of the identity of the individual, or as J.D. put it: “making
everyone work as a team.” Tasman writes “…the fundamental problem is a failure of integration of
disparate memories and aspects of self…such individuals suffer from having less than one
personality rather than more and than one.” This loss of self is a theme that has pervaded J.D.’s life,
and through the therapy and treatment of recent years, she seems to be regaining it back, side by
side with her “team”, of which only two remain. At the close of her interview, she stated that
although she was anxious about the future, she was thinking about it and what she would make out
of it for the first time that she could remember.
References
Carrion VG. Trauma and dissociation in delinquent adolescents. J Am Acad Child Adolescent Psychiatry 2000; 39: 353-9
Cole PM, Putnam FW. Effect of incest on self and social functioning: a developmental psychopathology perspective. J Consult Clin Psychology 1992;
60: 174-183
Tasman. Psychiatry, 1st edition, W.B. Saunders Company: 1997